Archive for the Law Category

Health Care and Veterans

Posted in Law, Politics with tags , , , , , , on January 15, 2010 by Josh Wittner

Yesterday a friend asked me about health care and it’s effects on veterans. Specifically she had been told by someone at her work that the health care bills now being merged by congress would create new premiums on veterans and she was wondering if this was true. At the time I couldn’t answer her question and decided to review the question in the morning.

After reviewing both the House’s Affordable Health Care For America Act and the Senate’s Patient Protection and Affordable Care Act (and this associated document specifically addressing questions about veterans) I can find no reason to believe that new premiums will be introduced to veterans enrolled in the Veterans Health Services program. Both bills explicitly state that administration of the Veterans Health Services will remain under authority of the Department of Veterans Affairs. Both bills explicitly state that the health care coverage supplied through the VHS meets the minimum eligibility requirements and so there will be no tax penalty for veterans enrolled in the program.

Veterans not enrolled in VHS however will be treated like any other citizen in that they will need to have health coverage, either through the Exchange or the VHS or a satisfactory third party or they will be required to pay the tax penalty.

If anyone out there has any further points on this or indeed any health care related concerns that they have or have heard other’s espouse, just let me know and I’ll help get to the bottom of it and try to provide you as true and clear a response as possible.

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Dissecting the Reason Healthcare Plan

Posted in Law, Philosophy, Politics with tags , , , , , , , , , , , on December 3, 2009 by Josh Wittner

Commenter Ovi, in response to my inquiry into options other than Universal Healthcare, provided this newly released video from Reason.

I’ll dissect it step by step.

The opening statement itself is misleading because it states that the system of insurance itself is the reason that most people don’t shop for price when it comes to health care, but other insurance industries however are incredibly competitive so the statement doesn’t make much sense. The real issue isn’t an insurance system, because the premiums of insurance are directly related to the cost of what the insurance covers, the real issue is that something like 90% of those insured by private health care get their health care through their employer and because of this have lost the sense of personal cost.

The comparison to the fall of non-advancing or stale services or products  like jeans and foodto health care is a poor comparison. As time goes by the cost of old medical technologies (that haven’t been surpassed by new technologies) has gone down, its the creation of newer and often less helpful medical interventions combined with a philosophy that health care should be distributed without pecuniary thought that have driven up medical costs. If health care was a stale industry or one like the utility industry, for example electricity that only adapts to cheaper alternatives, we wouldn’t have rising health care costs. People aren’t willing to pay whatever it takes to buy an apple or a pair of jeans but they are when it comes to medical procedures so the industry adopts new practices to support this and costs go up.

The statement “in 5/6th of the economy individual choice and competition works” is also misleading because it implies that other than health care the rest of the economy runs free of regulation and restriction which simply isn’t true. The electricity industry, which it uses as an example of a correctly functioning free market immediately before this statement, is often horribly limited in choice and competition and is one of the nations most heavily regulated industries.

The main problem I have with the Lasik example is that Lasik isn’t a life expectancy extending medical procedure (which is largely why it isn’t covered by medical insurance, the same way vision insurance is usually separate) and so it isn’t bound by the perspective problems that infect those that are. It is much easier to measure the convenience of no contacts/no glasses in dollar value than it is years of one’s life. Also medical technologies other than Lasik, including life extending ones, get cheaper and better as underlying technology (like lasers for Lasik) get cheaper and better. The implication in the video is that this isn’t true.

I don’t know enough about the Mass. health care system to make any reasonable comments about it, but this point only argues against the current health care proposals (if they do indeed mirror the Mass. system) and not against other functioning, cheaper, equally or more effective systems of universal healthcare.

Okay, now that we’ve hit the boiler plate intro stuff, it’s time to get into the 3 step plan.

The employer based system is a large concern and a clear problem with our health care system, but for better or worse it’s what we have. It’s often said that politics is the art of the possible, and in this case neither side of the aisle has much interest in removing it due to the pressures of the labor unions and companies that have spent tremendous effort creating and arguing for improved health insurance packages. Also a direct and forced removal of the employer based system would see a large premium increase for those 90% of people who have insurance through this system because their collective bargaining power would be removed (which provides them the cheaper and thus more comprehensive plans) and so there’s no constituent pressure to remove it either.

Who is this practicing physician that talks about going to the doctor to get blood pressure management (which can have drastic effects on life expectancy) advice and for information about resolving ingrown toenails (which can be  incredibly painful and debilitating) as wasted dollars? Certainly this information can be provided in cheaper ways (through things like simple science-based medical information websites for example) but that information is medically relevant and should be provided. It’s also important to be able to go to doctors for this kind of information because self diagnosis can be  a terribly dangerous thing to do. The thing is that a diagnostic doctors visit will inevitably be priced on the value of that doctor’s time and it doesn’t matter if you’re getting your potentially cancerous lump diagnosed or your toenail looked at the price will be the same.

I guess the real point here is whether doctor’s visits for these reasons should be covered by insurance or purely out-of-pocket. I’m not sure about the specific regulations on this so I’ll decline to comment on that aspect but in a purely free market I think it’s pretty speculative to state that there wouldn’t be plans that covered these things (especially if there’s enough constituent demand to get regulations on such coverage passed, which I don’t know if there has been).

The “all you can eat buffet” critique of our current system stands in stark contrast to the earlier comment about Mass. rationing health care. What is it guys, do you want rationing or not? And what exactly is better about the free market insurance companies rationing health care as opposed to the government doing so?

Extending the tax exemption to the individual health insurance market seems like a relatively good idea if we don’t fund it on the deficit. We’ll have to find cuts or other taxes to cover this new tax deduction, it won’t be free. I’m unsure of how extending the tax deduction to the individual market without completely removing the job based market provides individual workers with employer provided insurance more options.

The analogy of buying homeowner’s insurance after the fire to buying health insurance with a preexisting condition is relevant only in the case where someone hasn’t lost their previous insurance for some reason beyond their control. Perhaps the regulations forcing insurance to accept people with preexisting conditions is too broad and should be narrowed to only those who’ve lost their insurance because their previous insurance was forcibly severed either by the insurance company or because that individual lost their employer provided insurance, etc. Also if those who develop a condition while under insurance can’t freely change insurance because no insurer will pick them up now, how will the free market pressures operate? High risk individuals will have to stay with their current plans while low-risk individuals can move to cheaper plans which entirely defeats the point of insurance. Those who get sick will be punished as their premiums will continue to rise as the non-sick move to cheaper plans.

The troubles of mandated coverage is worded well here. We must be careful of what coverage we mandate that insurance companies provide because we can overstep our bounds. However the example of teetotallers paying for alcohol abuse treatment is flawed for a couple of reasons. First is that alcohol abuse is in large part influenced by environmental factors, including genetics and so saying that those who have had the chance to avoid these factors shouldn’t have to pay for the risk is like saying because my family doesn’t have a high risk of cancer I shouldn’t have to pay for a plan with cancer insurance. This builds a system where those who were born with high risks because of their lineage and their location are forced to pay much higher premiums for their coverage. Second is that it  implies that no mandated coverages should exist, in which case we end up with more instances of people who are uncovered for medical risks that didn’t turn their way and need either financial assistance or will simply burden our economy with bankruptcy when those costs are levied directly against them instead of the insurance pool. Does it overstep my feeling of individual liberty? Yeah, it does. But does it provide a better system of managing risk with lower negative effects on the economy? I think it does. At least we can agree that this point is much more complicated and expansive than the video makes it seem.

There are many ups and downs to allowing interstate health care market, and since this post is already way too long I’ll save those for another day. I’d suggest a little research on the topic though since it’s certainly not as simple as they make it out to be.

My understanding of the relevant studies on Health Savings Accounts is that they have little to no effect on health care costs as a whole because the amount that they’d cover represents an insignificant minority (1-2%) of health care costs. Any benefits would require an overhaul of the health care system that included changes to the availability of cost/quality information (of which there is just about none). I’m in favor of this even without HSAs. HSAs seem like a non-solution to rising health care costs.

Overall I didn’t find these offered solutions very compelling, but I agree with the end that either way what we’re doing now is just the start.  This solution overlaps the one provided provided the GOP in late October (I believe) in that both remove the interstate restrictions, both remove the preexisting conditions restrictions, and both would result in expensive high risk pools. The CBO review of the GOP health care proposal was abysmal with it only extending coverage to 7 million more Americans and reducing the deficit 68 billion where the Dem’s bill extends it to 36 million Americans and reduces the deficit by 104 billion. But hey, at least its free market principled!

The video in large didn’t present any new ideas and so I encourage any interested parties to research the points more and attempt to crush my statements. Or to provide arguments for why my points are otherwise invalid or unimportant.

And sorry for how long this is.

Universal Healthcare: A Response

Posted in Law, Politics, Religion, Science with tags , , , , , , , , , , , , on November 30, 2009 by Josh Wittner

My last post calling out Christians for not supporting Universal Healthcare when it seems like such a “Christ-like” action generated some comments that I’d like to more fully respond to because they are interesting and I hear a couple of them a lot, though I don’t agree with them, and so a new more Universal Healthcare oriented post is warranted.

Ovi writes:

I understand your point, but I would think the Christ-like decision would in fact be to support the church helping people in their own way, not by order of the King/State.

I don’t think Universal Healthcare in general works… There are people in Canada who have it and cross the border to the US because they have to wait to get treatment in their country… Countries in Europe who have similar systems get most of their medicine from the US because the best medicine and technology comes from the efficient competition-based free market of the US.

When you see stats about people who don’t have healthcare, keep in mind that some people don’t want it and others can in fact afford it, but just don’t get it for whatever reason. So the people who really need it and don’t have family and friends to help them and don’t go to current free clinics that are available, there are a very few of.

Lets take these one by one. First off, the bible is pretty clear that Jesus supports paying taxes (though certainly more vague about voting for legislation that will create taxes). We can extrapolate from this that either Jesus is in favor of bowing to power when taxes are concerned, or in general not opposed to taxation. So I stand by my statement that Jesus would vote for Universal Healthcare, and so supporting it would be a very Christ-like thing to do even if it increased taxes.

Secondly, I think before we can decide whether Universal Healthcare works, we need to define what “works” means. It is my belief that the goal of health care is to provide medical services that extend life, and that the best solution will extend life the most with the least cost. Literally every other industrialized country in the world has some form of Universal Healthcare so we should be able to compare our situation to theirs and determine at least if what we have works better than what they have.

Canadians do see a wait time for elective procedure (emergency procedures are of course handled immediately) but not all of the countries that have single-payer systems like Canada’s have the same problems, and the elderly in the US who use our single-payer system, Medicare (named after Canada’s) certainly don’t see any longer wait times than then non-elderly in the US. The proposals on hand don’t mirror the Canadian system very much, so this isn’t really on the table as an option anyways. I’d be willing to more thoroughly cover this if there is interest.

I haven’t run into any references to new medical technology production in Europe vs. the US but I have done some review of the production of new pharmaceuticals, often referred to as New Chemical Entities or NCEs. This study for example shows that the US dominance in the pharmaceutical industry is a myth and is in fact continuing to wain. Some argue that this isn’t because of the US’s high priced free-market so much as Europe’s ability to run more efficiently, though no one is positing why that is yet. Also we shouldn’t discount that most discovery research in the US is done largely with the $28 billion dollars in research funds provided by the NIH every year, the pharmaceutical companies tend to pick up drugs only after they’re ready for clinical trials. The NIH is a tax funded institute of the US government.

So lets compare the metrics of other countries with the US for health/cost to determine which system works better by my definition of works. The US spends per capita more money on health care than any of its industrialized counterparts, in fact nearly twice as much. The US also sees 60% of its bankruptcies related to medical bills, something that simply doesn’t happen in other developed countries. The argument here goes that we see better outcomes, that is, you get what you pay for. But this simply isn’t true either. The US has the lowest life expectancy and highest infant mortality rates of any of its industrialized contemporaries. We spend more on health care as a percentage of GDP than any other country in the world yet the WHO ranks us as 37th out of 191, just above Slovenia.

The waiting lists in Canada are used as form of rationing health care usage over time, and is rightly pointed out as such, but arguing against rationing is not arguing against Universal Healthcare. The US has rationing too, but it’s done more amorally: we let poor people die. Other systems spend less, get better outcomes, and quite frankly evince more compassion than our system.

Finally, making the statement that a significant number of the 35+ million Americans who don’t have health insurance, or even more so the roughly 45,000 Americans who die every year due to it’s lack, don’t want health insurance seems seriously absurd, but may be worth investigating. I couldn’t find any research addressing the question and I don’t think it’s overstepping to speculate that its because everyone thinks it’s obvious, but I would support research into the issue.

I invite Ovi to contradict anything I’ve said here and to more thoroughly support his points as well. Also I’d be interested in his thoughts on taxation in general so that I could more thoroughly understand them. For example, “Do you seek to remove all taxes?” Also if anyone has more questions or wants sources for the things I didn’t provide (which are plenty) I’ll gladly dig em’ up again (this is a standing invitation for anything I write).

Individual Mandates and The Constitution

Posted in Law, Politics with tags , , , on November 6, 2009 by Josh Wittner

One of the most controversial aspects of the health care debate is the notion of the individual mandate. The argument is that in order make the demand on insurers that they cannot exclude coverage or drastically differentiate prices for consumers based on preexisting conditions tenable (either politically or in actuality) then the insurance pools must include more healthy people. To ensure that healthy people enter the pool, whom individually have no incentive to buy health insurance if they know that they can get it after they get sick because insurance companies can’t reject them based on preexisting conditions, an individual mandate is put in place requiring everyone to purchase health insurance.  The controversy is usually pretty straight forward, boiling down to concern over the infringement of individual liberties. Whether or not we believe our government should have the right to create such a mandate, the immediately relevant question is whether creating such a mandate is constitutional or not, that is, do they have the power?

This online debate does a good job of providing the rough arguments for and against constitutionality claims concerning individual mandates to purchase products or services. This blog post collection does a good job of expanding on the ideas, creating more nuanced arguments about the constitutionality of individual mandates but does somewhat digress at the end into an argument over what “constitutionality” means and should mean. Also some interesting perspectives concerning the power politics exerts on the judicial branch.

The main argument for constitutionality is that under the Commerce Clause, which grants congress the right to regulate commerce “amongst the several states”, congress does have the power to mandate individuals in this manner because purchasing health insurance has economic effects involving interstate commerce. Some strong applications of the Commerce Clause have been the regulation of wheat grown for personal consumption, the regulation of marijuana grown for personal consumption, and upholding the “Gun Free School Zones Act” in United States v. Lopez all of which were upheld because of a connection between these acts and interstate commerce.

The main argument against constitutionality is that while not purchasing health care is certainly an economic decision and has effects on interstate commerce, allowing regulation of such cases applies the Commerce Clause far too broadly and in completely unprecedented ways. Considering that nearly every aspect of our behavior has some economic impact that permeates the whole of the economic scene applying the Commerce Clause in such a way give congress the capability to control every aspect of our individual spending and in fact our personal lives. The argument also follows that the Commerce Clause was not intended to be applied in this way because these results violate the idea that The Constitution provides congress with limited, enumerated powers. It also points out that an act of economic abstaining isn’t necessarily the same as an active economic act when regulation is in question.

I am personally somewhat of a federalist in that I approve of a strong interpretation of the tenth amendment and generally prefer my legislation closer to the chest than the national level. So it shouldn’t be much of a surprise that I lean toward the argument against constitutionality. It seems clear to me that there is a substantial difference between not purchasing health care and growing marijuana. Also if it so happens that there is not available at all levels a non-profit option for healthcare I think the mandate becomes an even greater violation of individual rights and its constitutionality becomes an even more important question. I would be a stronger advocate of a single-payer style system that was funded via taxes because I thinks its simpler and probably has a stronger constitutional argument for it.

I’d write more, but work calls. I’m interested in what you guys think.